Evaluation of the hip joint a snapshot summary (Nov 2012)

Key messages
Although the literature frequently examines clinical tests in isolation, good
practice and higher quality evidence strongly assert the need to use multiple
tests in addition to other aspects of the consultation.
The trendelenburg test may be limited in its use for assessing hip abductor
muscle strength and in identifying patients with early osteoarthritis of the hip.
FABER test has been shown to be sensitive in more than one study but its
specificity has not yet been established. The tests inter-reliability has also been
shown to be good.

Context
This is the starting point for all clinicians and excludes the presence of abdominal
pathology or other systemic conditions that could contribute to symptoms in the hip
and thigh region. Hip joint disease can co-exist with other pathologies, referred
symptoms, secondary dysfunction, or other coincidental findings.
A variety of disorders can suggest a painful hip. Byrd and Jones1 assert that although
examination of the hip can be very reliable at detecting the presence of a problem, it
may be poor at defining specifically the true nature of the underlying disorder.
Byrd2 suggests that a history of a significant traumatic event is a good prognostic
indicator of a potentially correctable problem, while an insidious onset is a poor
prognostic indicator suggestive of degenerative disease or some other predisposition to
injury.

Leibold et al3 state that characteristic features to be considered for differential

diagnosis vary depending on the age of the patient. In childhood, for example, disorders
for differential diagnosis include congenital dysplasia, Legg-Calve-Perthes disease, and
slipped capital femoral epiphysis. Leibold et al3, explore further different differential
diagnoses. These include the consideration of infectious conditions, traumatic
conditions, inflammatory conditions, degenerative joint disease, neurological
conditions, vascular conditions, metabolic conditions, neoplasms, and other causes
including referred pain, corticosteroid use, alcoholism, psychosocial factors, and
gynaecological disorders.

Physical examination
Byrd2 stated that the physical examination should include:
Inspection Identification of antalgic gait in a patient when entering the treatment room
Observation of the patients posture when standing and seating
Any protective postures to alleviate stresses on the hip
Any flexion of the symptomatic hip
Slouching to the symptomatic side when sitting
Gross atrophy of any muscle groups or other asymmetries
Measurement
Limb length from the anterior superior iliac spine to the medial malleolus.
Byrd2 asserts that a discrepancy greater than 1.5cm can indicate a variety of chronic
conditions.
Bilateral thigh circumference to assess for muscle atrophy
Range of motion recorded consistently and in a reproducible and comprehensible
manner
Symptom localisation
The one finger rule asking the patient to place one finger on the spot that hurts most
C-sign patients will often cup their hand around the most symptomatic region
Palpation this can be conducted systematically working from the lumbar spine, pelvic
joints, along the iliac crest to the greater trochanter, and including muscle bellies.

Muscle strength Byrd2 states that although this is a crude measure of hip function, it
can reveal useful information, and active resisted assessment can reproduce pain.
Log Rolling

Byrd2 asserts this is the single most specific test for hip pain. The
rolling back and forth of the hip moves the femoral head in relation
to the acetabulum, and the absence of a positive log roll test raises
the suspicion that the hip is not a source of symptoms.

Obers Test

This test, first described in 1936, is a common and widely accepted

test for measuring the length of the iliotibial band4. Ober first
described the test with the knee flexed but additional literature
failed to demonstrate an accepted standardised position for the
knee. A cross-sectional comparative repeated measures design was
undertaken to assess the influence of gender and knee position on
Obers test4. A sample of 49 asymptomatic participants were
assessed using Obers test with the knee flexed to 90 and extended
to 0 for the right lower limb. The limb was lowered from abduction
and the end point of hip abduction, or hip adduction was measured
in relation to neutral4.
The researchers found that the Ober test with the knee flexed limited
hip adduction more than with the knee extended for both men and
women, and women had greater limitations than men4. In this case, it
could be argued that as the Ober test with the knee flexed and knee
extended produced different results, they could be considered to be
two distinct tests. Gajdosik et al4 suggested that normative values for
the two knee positions should be defined separately for men and
women.

Thomas Test

The Thomas test, also known as the Kendall test, has been discussed
in its various modifications by a range of authors in its application of
assessing flexibility in the thigh region. Peeler and Anderson5
undertook a descriptive test-re-test design to evaluate the clinical
reliability of the test. Normative limits had not been established for
rectus femoris flexibility prior to this study. A total of 54 participants
completed the study. The rectus femoris was assessed for 90
flexibility using pass/fail, and goniometer scoring systems. A re-test
session was undertaken ten days after the initial test phase.
Statistical evaluation of the findings indicated generally poor levels
of reliability for pass/fail scoring, and fair to moderate levels of
reliability for goniometer data. Measurement error values
demonstrated further the degree on intra-rater variance when
conducting the test.
Peeler and Anderson5 concluded that the findings raise questions
concerning the reliability of the modified Thomas test and provide
new information concerning its reliability when assessing the
flexibility of rectus femoris in a clinical setting.

Trendelenburg
Test (TT)

Hardcastle and Nade6 examined the significance of the

Trendelenburg test (TT) in clinical practice. The test was originally
described in 1897 at a time when clinicians had few diagnostic aids
other than their senses. Hardcastle and Nade6 identified four
different methods of performing the test in standard texts. In their
own study they examined 50 asymptomatic subjects, and 103
subjects with disorders of the spine or hip who were further
subdivided into subjects with neurological disorders or mechanical
disorders. Their study identified a means of standardising the test,
and allowing interpretation of the test to assess hip abductor
function.
Hardcastle and Nade6 used a standardised approach for the test by
asking their subjects to stand initially with the non-stance leg flexed
to 30, and this was repeated with the leg flexed to 90. Each posture
was held for 30 seconds. Postures were recorded using photography,
videotape, electromyography, and assessment of abductor muscle
power.
The study found that three different patterns of movement occurred
in the spine and pelvis. These were:
The pelvis rising on the non-stance side with a compensatory
scoliosis convex to the stance side, classified as a negative TT.
The pelvis remained parallel to the ground with minimal
spinal compensation
The pelvis dropped on the non-stance side accompanied by
downward movement of the buttock crease with associated
abduction of the weight bearing hip, and compensatory
scoliosis convex to the stance side. This was classified as a
positive TT.
The authors noted that the major issues arising from the test focused
on misinterpretation. These included false positive responses arising
from pain, lack of patient cooperation, and impingement between the
rib cage and the iliac crest. False negative responses resulted from
patients using muscles from above and below the pelvis, and from
leaning beyond the hip on the stance side.
Kendall et al7 recently conducted a study to investigate the validity of
this test using an ultrasound-guided nerve block (UNB) of the
superior gluteal nerve to determine whether or not the reduction in
hip abductor (HABD) muscle strength would result in the mechanical
compensatory mechanisms expected in a positive test. After testing
9 healthy males the authors found that despite an average strength
reduction of 52% of HABD muscles following the UNB, no significant
mechanical changes could be seen during the test. Youdas et al8
concluded that TT was not useful in identifying patients with early
hip OA due to poor validity of the test when they compared a group
of patients with mild OA to a healthy group. Furthermore, Kendall et
4

al9 found in their earlier study of patients with non-specific low back
pain that the TT did not show a correlation between HABD strength
and the amount of mechanical pelvic drop in the test. They suggested
that there may be other factors controlling pelvic stability.
Elys Test

Elys test is one of many used to assess flexibility of the rectus

femoris (RF) muscle. Its reliability as a clinical tool was assessed by
Peeler and Anderson10. They employed experienced clinicians to use
Elys test in a test- re-test design to assess RF flexibility and
evaluated this using pass/fail and goniometer scoring systems.
Statistical analysis of the findings led the researchers to call into
question the statistical reliability of Elys test. This provides
practitioners with helpful information on the reliable limits of the
test when used in a clinical setting.

FABER
(Patricks test)

Maslowski et al11 carried out four hip pain provocation techniques

on 50 subjects prior to them receiving an anaesthetic injection into
the hip joint. They used the FABER test, Stinchfield manoeuvre,
Scour manoeuvre (quadrant test) and internal rotation with over
pressure (IROP). They found that the FABER test was sensitive in
identifying intra-articular hip pathology but was not shown to be
specific due to the study design and therefore could not yet be relied
upon to be negative in patients without hip pathology.
Martin and Sekiya12 undertook an evaluation of four clinical tests
used to assess individuals with musculoskeletal hip pain. They
evaluated inter-rater reliability of the FABER test, flexion- internal
rotation-adduction impingement test, log roll test, and the palpation
of the greater trochanter for tenderness. A total of seventy
symptomatic subjects (mean age 42 years) were evaluated by an
orthopaedic surgeon, and physical therapist. Their diagnoses
included degenerative joint disease, labral tear, femoroacetabular
impingement, capsular laxity, trochanteric bursitis, iliopsoas
tendonitis, and adductor strain. Statistical evaluation was
undertaken on the findings of the tests. Martin and Sekiya12
concluded from their findings that the FABER test, log roll test, and
assessment of greater trochanteric tenderness showed a fair level of
agreement. Low reliability was found for the flexion- internal
rotation-adduction impingement test.

Internal rotation Maslowski et al11 found IROP to be the most sensitive test of the four
with over
used in their study described above However, as with the FABER test
pressure (IROP) it was not shown to be specific.

Author: Carol Fawkes, NCOR Research Development Officer

Updated by: Elena Ward, NCOR Research Assistant

References
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and intra-articular injection of hip arthroscopy patients. American Journal of Sports.
2004;32:1668-1674.
2. Byrd JWT. Evaluation of the hip: history and physical examination. North American
Journal of Sports Physical Therapy. 2007;2(4):231-240.
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examination tests for hip labral lesions: a systematic review. Journal of Manual and
Manipulative Therapy. 2008;16(2):E24-41.
4. Gajdosik RL, Sandler MM, Marr HL. Influence of knee positions on the Ober test for leg
length of the iliotibial band. Clinical Biomechanics. 2003;18:77-79.
5. Peeler JD, Anderson JE. Reliability limits of the modified Thomas test for assessing
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Abductor Muscle Function on Frontal Plane Mechanics. Clinical Journal of Sports
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11. Maslowski E, Sullivan W, Forster Harwood J, Gonzalez P, Kaufman M, Vidal A,

Akuthota V (2010). "The Diagnostic Validity of Hip Provocation Maneuvers to Detect
Intra-Articular Hip Pathology." American Academy of Physical Medicine and
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individuals with musculoskeletal hip pain. Journal of Orthopaedics and Sports Physical
Therapy 2008;38(2):71-77.